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30 - Funct.dis of Dig.syst.
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Transcript of 30 - Funct.dis of Dig.syst.
11
Functional Functional Disordes of Disordes of
Digestive SystemDigestive System
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Functional disorders
no structural, biochemical, or infectious etiology has been found
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Functional Disordersof Digestive System (FDDS)
are are reported by 25% of the adult population female predominance > 2:1 among patients
presenting to a physician < 50% of patients with FDDS apply to the
physicians 75% of patients try to treat themselves
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Functional Disordersof Digestive System (FDDS)
EEsophageal sophageal GastroduodenalGastroduodenal Intestinal Intestinal Functional abdominal painFunctional abdominal pain Biliary Biliary dyskinesia Anorectal disorders Anorectal disorders Noncardiac chest pain Nonulcer dyspepsia Pediatric FDDSPediatric FDDS
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Aetiology Aetiology
Disordered motor or sensory function of the GI tract
Altered visceral sensation
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EEsophageal sophageal Functional Functional DisordersDisorders
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EEsophageal sophageal FDFD
61,7% of men and 63,6% of women suffer 61,7% of men and 63,6% of women suffer 77from from heartburnheartburn..
Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease (GERD): (GERD): 40-60%40-60% of adult population. of adult population.
EsophagitisEsophagitis is revealed is revealed in in 45-80% 45-80% of patients of patients with GERDwith GERD
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Pathogenesis of GERDPathogenesis of GERD Decreasing of Antireflux BDecreasing of Antireflux Barrierarrier:: - Pressure decreasing in the lower esophageal - Pressure decreasing in the lower esophageal
sphincter sphincter - Increasing of spontaneous relaxation episodes of - Increasing of spontaneous relaxation episodes of
the lower esophageal sphincter the lower esophageal sphincter - Complete / incomplete destruction of the lower - Complete / incomplete destruction of the lower
esophageal sphincter esophageal sphincter Esophageal Clearance Decreasing:Esophageal Clearance Decreasing: - Chemical- Chemical - V- Volumetric – olumetric – due to due to oppression oppression of the secondary of the secondary
peristalsis and wall tonus diminishing of the peristalsis and wall tonus diminishing of the thoracic part of the esophagusthoracic part of the esophagus
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Pathogenesis of GERDPathogenesis of GERD
Damage Damage propertiesproperties of refluctant of refluctant Stomach emptying disorders Stomach emptying disorders Abdominal pressure increasingAbdominal pressure increasing Connective tissue disorders (hiatal hernia) Connective tissue disorders (hiatal hernia)
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Diagnosis of GERDDiagnosis of GERD
EndoscopyEndoscopy ManometryManometry pHpH--metrymetry X-rayX-ray
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TreatmentTreatment
““Life style / modus” normalization (eating 4-6 Life style / modus” normalization (eating 4-6 times a day)times a day)
Diet (to eat suitable food)Diet (to eat suitable food) AntacidsAntacids ProkineticsProkinetics
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Stomach Functional Stomach Functional DisordersDisorders
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Stomach FDStomach FD
Functional dyspepsyFunctional dyspepsy AerophagyAerophagy Functional vomitingFunctional vomiting
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Functional dyspepsyFunctional dyspepsy Ulcer-like Ulcer-like
epigastric pain (fasting or night) stopped epigastric pain (fasting or night) stopped by antacids by antacids
DyskineticDyskinetic
early satiety, nausea, abdominal early satiety, nausea, abdominal distension just after eating of distension just after eating of small small amountamount of the food of the food
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Pathogenesis of Stomach Functional Pathogenesis of Stomach Functional Dyspepsy (SFD)Dyspepsy (SFD)
Decreasing of Decreasing of gastric motor activitygastric motor activity (antral (antral part) - gastroparesispart) - gastroparesis
Stomach Stomach dysrhythmiadysrhythmias (tachygastria, s (tachygastria, bradygastria)bradygastria)
Antrocardial and antroduodenal coordination Antrocardial and antroduodenal coordination disturbance disturbance
Duodenogastric refluxDuodenogastric reflux Stomach proximal part relaxation disturbanceStomach proximal part relaxation disturbance Visceral hVisceral hypersensitizationypersensitization of the stomach of the stomach
wall to distension wall to distension
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Investigation dataInvestigation data
Light epigastric pain in palpation without Light epigastric pain in palpation without anterior abdominal wall tensionanterior abdominal wall tension
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Differential diagnosis withDifferential diagnosis with
UlcerUlcer GallstonesGallstones Chronic pancreatitisChronic pancreatitis TumoursTumours
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Treatment of SFDTreatment of SFD
““Life style / modus” normalization Life style / modus” normalization (eating 4-6 times a day)(eating 4-6 times a day)
PPsychotherapysychotherapy / / PPsychosychopharmacopharmacotherapytherapy
Prokinetics /normokineticsProkinetics /normokinetics SpasmolyticsSpasmolytics H2-histamine blockersH2-histamine blockers
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IRRITABLE BOWEL SYNDROME
(IBS)
2020
IBSIBS
is characterized by abdominal pain and altered bowel habits, including diarrhea, constipation, or alternating diarrhea and constipation
Symptoms are typically intermittent but may be continuous
Symptoms should be present for at least 3 months before a diagnosis of IBS is considered
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IBSIBS
55 –– 1919 % % in men in men 1414 –– 2424 % % in womenin women Men / women = Men / women = 1,51,5 :: 2,52,5 DDisease incidenceisease incidence peak = 30 - 40 y.o. peak = 30 - 40 y.o.
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IBSIBS
18921892 y. - “ y. - “mucous colitismucous colitis” – English ” – English doctor W. Oslerdoctor W. Osler..
19291929 y.- y.- ““Irritable bowel” - S. Jordan S. Jordan andand E. KiferE. Kifer
Russian doctor Russian doctor А.В. Фролькис А.В. Фролькис (A.V.Frolkis) – “(A.V.Frolkis) – “dyskinesia of colondyskinesia of colon””
IRRITABLE BOWEL SYNDROME - now
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Manning criteria
abdominal pain or discomfort that is relieved by defecation or associated with a change in stool frequency or consistency,
abdominal distention, sensation of incomplete evacuation, passage of mucus (in faeces)
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Roman criteriaRoman criteria
Diagnostic criteria for IBS that incorporate the Manning criteria have been established to standardize research and may be useful in clinical practice - римские критерии синдрома раздраженной кишки
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IBSIBS
PredominancePredominance of of diarrheadiarrhea PredominancePredominance of of constipationconstipation PredominancePredominance of of abdominal pain and abdominal pain and
distensiondistension
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IBS: IBS: PredominancePredominance of of diarrheadiarrhea
Liquid stool 2 – 4 times a day, morning, Liquid stool 2 – 4 times a day, morning, agter breakfast, mucous and remnants of agter breakfast, mucous and remnants of undigested food in the feces undigested food in the feces
Feeling to make a defecation urgently / Feeling to make a defecation urgently / promptly promptly
Absence of diarrhea during night, but Absence of diarrhea during night, but ““Morning alarm-clockMorning alarm-clock””
Feces weight < 100 g.Feces weight < 100 g.
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IBS: IBS: PredominancePredominance of of constipationconstipation
Absence of defecation during > 3 Absence of defecation during > 3 days.days.
AAlternation lternation of diarrhea and of diarrhea and constipationconstipation
Feeling of incomplete evacuationFeeling of incomplete evacuation ( ( lumpy/hard, tape-like or pencil-like)lumpy/hard, tape-like or pencil-like)
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IBS: IBS: PredominancePredominance of of abdominal abdominal pain and distensionpain and distension
CCramp-like, spasmodicramp-like, spasmodic abdominal pain abdominal pain Pain Pain increases beforeincreases before defecation and defecation and decreases decreases
afterafter one one Pain occurs after eatingPain occurs after eating MeteorismMeteorism Abdominal tenderness, often in the left /right
lower quadrant in palpation or along all parts of bowel
3131
““Alarm” signs – Alarm” signs – exclusionexclusion criteria of IBS criteria of IBS
Constant abdominal pain, increasing after Constant abdominal pain, increasing after defecationdefecation
Night pain, diarrhea and other sympromsNight pain, diarrhea and other symproms Causeless weight lossCauseless weight loss Onset of the “IBS” at age > 50 y.Onset of the “IBS” at age > 50 y. Oncological diseases of bowel in relativesOncological diseases of bowel in relatives Fever > 37,4Fever > 37,4OOCC
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““Alarm” signs – Alarm” signs – exclusionexclusion criteria of IBS criteria of IBS
Hepato-, spleno-, thyroidmegalyHepato-, spleno-, thyroidmegaly AnemiaAnemia Increasing of WBC and ESRIncreasing of WBC and ESR Blood in fecesBlood in feces Deviationa in biochemical blood Deviationa in biochemical blood
analysisanalysis
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ObligatoryObligatory lab lab teststests
Common blood test (RBC,WBC, ESR,...)Common blood test (RBC,WBC, ESR,...) UrinalysisUrinalysis CoprogrammCoprogramm Feces culture (Feces culture (dysbacteriosisdysbacteriosis)) Occult blood in fecesOccult blood in feces Blood: total bilirubin, AST, ALT, GGTP, Blood: total bilirubin, AST, ALT, GGTP,
alc.phosphatase, markers of intestine alc.phosphatase, markers of intestine infections, immunnoglobulinsinfections, immunnoglobulins
Intestine hormones in case of severe diarrhea Intestine hormones in case of severe diarrhea
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ObligatoryObligatory instrumental instrumental investigationsinvestigations
ProctosigmoidoscopyProctosigmoidoscopy IrrigoscopyIrrigoscopy Endoscopy with biopsy of distant part of the Endoscopy with biopsy of distant part of the
duodenumduodenum X-ray examination of the stomach and small X-ray examination of the stomach and small
intestineintestine Colonoscopy with biopsyColonoscopy with biopsy Abdominal SonographyAbdominal Sonography
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ObligatoryObligatory instrumental instrumental investigationsinvestigations
pH-metrypH-metry Sphincteromanometry (in case of Sphincteromanometry (in case of
constipation)constipation) Electromyography of pelvic musclesElectromyography of pelvic muscles EnterographyEnterography Consultation of psychologist, Consultation of psychologist,
gynecologists, urologistsgynecologists, urologists
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Treatment of IBS with Treatment of IBS with diarrhea diarrhea predominancepredominance
Diet – 4 (B)Diet – 4 (B) Dietary modifications PsychotherapyPsychotherapy LoperamideLoperamide - motility regulation - motility regulation CholestyramineCholestyramine SmectaSmecta – – adsorbentadsorbent, coating drug, coating drug Probiotics – Probiotics – Linex, Hylak-forteLinex, Hylak-forte
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Treatment of IBS with Treatment of IBS with constipation constipation predominancepredominance
WheatWheat--branbran ( (отруби)отруби) ForlaxForlax Motilium, CisaprideMotilium, Cisapride Probiotics – Probiotics – Linex, Hylak-forteLinex, Hylak-forte
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Treatment of IBS with Treatment of IBS with pain pain predominancepredominance
Antispasmodics: Antispasmodics: Meteospasmyl, Meteospasmyl, Duspatalin, SpasmomenDuspatalin, Spasmomen
AntidepressantsAntidepressants
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Biliary Biliary dyskinesia
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Biliary Biliary dyskinesia
Motility and secretory Motility and secretory discoordination of gallbladder and discoordination of gallbladder and sphincters of extrahepatic bile ductssphincters of extrahepatic bile ducts
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Biliary Biliary dyskinesia
80% of children with GI problem80% of children with GI problem There are no finding of adultsThere are no finding of adults Men : women = appr. 1: 3Men : women = appr. 1: 3
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Classification Classification
PrimaryPrimary Secondary Secondary
Motility disturbance forms:Motility disturbance forms: Hypertonic-hyperkineticHypertonic-hyperkinetic Hypotonic-hypokineticHypotonic-hypokinetic MixedMixed
- - Oddi’s sphincterOddi’s sphincter dysfunction dysfunction - gallbladder dysfunction - gallbladder dysfunction
4343
Aetiology and pathogenesisAetiology and pathogenesis
Parasympathetic or sympathetic Parasympathetic or sympathetic tonus predominance leads to tonus predominance leads to hypertonic or hypotonic dyskinesia hypertonic or hypotonic dyskinesia
In duodenal disorders – In duodenal disorders – cholecystokinin production cholecystokinin production disturbancedisturbance
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Screening testsScreening tests
Liver functional testsLiver functional tests Pancreatic enzymes in the blood and Pancreatic enzymes in the blood and
urineurine SonographySonography Esophagogastroduodenoscopy Esophagogastroduodenoscopy
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SpecializeSpecialized testsd tests
Sonography with GB and Sonography with GB and Oddi’s Oddi’s sphinctersphincter function estimationfunction estimation
ERCPG with ERCPG with Oddi’s sphincterOddi’s sphincter manometrymanometry
Isotope scanning Isotope scanning 9999Tc of the liver and Tc of the liver and bilebile
Drug-tests with cholecystokininDrug-tests with cholecystokinin
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Primary causesPrimary causes of GB evacuation of GB evacuation disturbancedisturbance
GB smooth muscles disturbance GB smooth muscles disturbance (decreasind of muscle weight or (decreasind of muscle weight or sensitivity to neurohumoral stimulus)sensitivity to neurohumoral stimulus)
Function discoordination between Function discoordination between GB and choledochGB and choledoch
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Secondary causesSecondary causes of GB evacuation of GB evacuation disturbancedisturbance
Hormonal disorders – pregnancy, Hormonal disorders – pregnancy, hormonal treatment (somatostatin) hormonal treatment (somatostatin)
Post-surgeon conditions (vagotomy, Post-surgeon conditions (vagotomy, stomach resection,…)stomach resection,…)
Diseases – diabetes mellitus, liver Diseases – diabetes mellitus, liver cirrhosis,…cirrhosis,…
GBS and cholecystitisGBS and cholecystitis
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Clinical featuresClinical features
Hypertonic-hyperkineticHypertonic-hyperkinetic dyskinesia – dyskinesia – short, colic pain in the right short, colic pain in the right hypochondrium, some times a dayhypochondrium, some times a day
Hypotonic-hypokineticHypotonic-hypokinetic dyskinesiadyskinesia - - constant, dull, long lasting pain in the right constant, dull, long lasting pain in the right hypochondrium with nausea and hypochondrium with nausea and bitterbitter / air / air eructationeructation
4949
X-ray and Lab criteria of X-ray and Lab criteria of Hypertonic-hyperkineticHypertonic-hyperkinetic dyskinesia dyskinesia
CholecystographyCholecystography: :
- small GB- small GB
- prolongated bile evacuation- prolongated bile evacuation
- GB hypercontracton after Boyden test meal- GB hypercontracton after Boyden test meal Duodenal TubageDuodenal Tubage: :
- small amount of B-portion (GB bile) < 30 ml- small amount of B-portion (GB bile) < 30 ml
- prolongated bile evacuation from GB > 30 min- prolongated bile evacuation from GB > 30 min
- - apparentapparent GB answer to irritation GB answer to irritation
5050
X-ray and Lab criteria of X-ray and Lab criteria of
Hypotonic-hypokineticHypotonic-hypokinetic dyskinesia dyskinesia
CholecystographyCholecystography: : - large GB- large GB - prolongated bile evacuation - prolongated bile evacuation - GB hypocontracton after Boyden test meal < - GB hypocontracton after Boyden test meal <
½ of previous volume½ of previous volume Duodenal TubageDuodenal Tubage: : - large amount of B-portion (GB bile) > 60 ml- large amount of B-portion (GB bile) > 60 ml - prolongated bile evacuation from GB > 60 - prolongated bile evacuation from GB > 60
minmin - low GB answer to irritation- low GB answer to irritation
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Treatment of Treatment of Hypertonic-hyperkineticHypertonic-hyperkinetic dyskinesia dyskinesia
Low-fat diet (Low-fat diet (№ № 5)5)
AntispasmodicsAntispasmodics
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Treatment of Treatment of Hypotonic-hypokineticHypotonic-hypokinetic dyskinesia dyskinesia
Vegetable fat, eggs, fruits, branVegetable fat, eggs, fruits, bran Physical exercisesPhysical exercises ProkineticsProkinetics Cholecystokinetics (MgSOCholecystokinetics (MgSO44, xylite, , xylite,
Hepabene,…)Hepabene,…)